Provider Demographics
NPI:1194751594
Name:SANFORD CLINIC NORTH
Entity type:Organization
Organization Name:SANFORD CLINIC NORTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:K
Authorized Official - Last Name:LECLERC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-234-6248
Mailing Address - Street 1:2601 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-6704
Mailing Address - Country:US
Mailing Address - Phone:701-234-2900
Mailing Address - Fax:701-234-2996
Practice Address - Street 1:2601 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-6704
Practice Address - Country:US
Practice Address - Phone:701-234-2900
Practice Address - Fax:701-234-2996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN027813100Medicaid